Lip Reconstruction is performed when a surgeon has to repair or reconstruct a portion of the lip area due to a variety of reasons including congenital issues like a cleft lip and palate, cancer, or traumatic injuries like electrical burns or dog bites. Someone might have a lip deformity due to a previous surgery that was in the vicinity of the anatomical region of the lips such as cancer surgery, a broken bone in the cheek, or nose that extended towards the lip and dog bite injuries. Dog bites are a big reason for lip reconstruction because they are typically issues that are nasal, facial, and lip-oriented.
There are many cultural and gender differences between the lips. Paying attention to these differences helps a doctor reconstruct a traumatic injury because the size and form can vary slightly between males and females of different ethnicities.
There are three basic anatomical layers to reconstruct and they include the skin, the muscle, and the oral mucosa. Function is always the first priority and plastic surgery deals with function and form. Both are important, but the lips perform specific functions such as speech, eating, aspects of breathing, and facial expression. For example, the source of the deformity dictates which approach and which technical procedure the surgeon will use. The principles, as mentioned above, are reconstructing for function and then form utilizing all of the layers of the lip, the mucosa, the muscle and the skin.
The external skin has specific anatomical regions of the upper lip such as mucosa. As it transitions to the skin from the actual lip part, there is the white roll and the vermilion border and then the Cupid’s bow and the philtral columns which are the central portion of the upper lip. The Cupid’s bow is a silhouette shape of a bow in archery that goes across the upper lip and the two vertical columns that go to the base of the nose are the philtrum. All of those aspects, including the vermilion border, are important when doing reconstruction of the upper lip. The lower lip does not have all of those same anatomical structures so the approach can be slightly different.
A baby with a cleft lip deformity is normally treated by reconstructing the cleft lip. The cleft lip has a wide opening between the upper lip, philtral columns, and the lateral lip segments because they did not fuse in utero. A typical approach is to perform a rotation advancement flap which rotates the muscle and the philtral column down from the medial lip segment and then advances the lateral lip segment into the defect. Those areas are then sutured closed. The surgeron utilizes part of the cheek and the lateral lip segment to advance into the defect and reconstruct while rotating the medial lip segment down. Reconstructing the muscle gives function because then the lip will actually work. Without muscle closure the lip will not work effectively so the surgeon needs to make sure the orbicularis muscle from both the lateral segment and the medial segment are reconstructed and sutured together. The oral mucosa and skin are sutured together and then the vermilion border is lined up to recreate the symmetry and form of the Cupid’s bow.
There are multiple flaps such as the Abbe flap or cross-lip flap which uses the lower lip to reconstruct the upper lip. Those segments are attached for 10 to 14 days and then removed or divided and reconstructed during a second stage operation. These flaps are very effective for upper lip reconstruction.
There are also Estlander flaps which are more towards the lateral commissure. There are Karapandzic flaps where the surgeon rotates tissue from the cheeks to reconstruct very large defects of the lower lip.
Finally, there are basic flaps such as V-Y advancement flaps which are used to fill in defects of the lower or upper lip by utilizing oral mucosa in order to reconstruct an area of missing tissue. It is a very nuanced and artistic specialty because the surgeon has to be creative at times and utilize the surrounding tissue as best as possible. Sometimes the surrounding tissue and the blood supply to that tissue are damaged, so the surgeon has to make do with what is available. Many times, there has to be a temporary reconstruction to close wounds and then a revised reconstruction at a later date in order to make the form better.
Revision surgery is very common but it does depend on the individual patient. Someone can have a lip defect that often needs revisions in order to:
After a certain amount of time has passed, the surgeon goes back and does a scar revision to improve on what was previously done. It varies according to the individual situation.
A lot of plastic surgery involves managing expectations because these injuries can have long lasting psychological effects. Patients are counting on the surgery to give them results that are acceptable and they can deal with for the rest of their lives.
A common postsurgical deformity of cleft lip repair is that one side of the lip being flatter than the other and a flattening of the nasal ala is present as well. They can be reconstructed using injectable fillers or fat transfer to augment the lip and give a better contour, form, and fullness. It can help with the reconstruction and it is a cosmetic tool as well.
In general, most defects can be repaired but smaller defects have a better chance of retaining function and form. If the defects are less than 2-cm to 3-cm, there is a better chance of having enough tissue in the surrounding area to reconstruct. Even when the defects are larger, the surgeon can still utilize the flaps to do reconstruction. If the defects become very large, the function and form that is acceptable in those situations is different than a smaller defect.
It gets more technical and complex in the area of oral cancers where part of the lip muscle mucosa and the bone are often removed from people with squamous cell carcinomas or throat cancers. Taking tissue from another part of the body and bringing it into the facial region and reconnecting the blood vessels, arteries, and veins is a very technical aspect of plastic and reconstructive surgery called free tissue transfer or free flap reconstruction. This can be utilized for very large defects of the face and mouth for reconstruction but the actual outcomes and expectations are much different than smaller defects.
Because perfusion of the vessels and blood flow is important to the viability of any flap, people who are diabetic or smokers are at a higher risk for complications. Smokers can have a higher risk of complications such as flap death or flap necrosis. Fortunately, flaps and surgeries in the facial region are very rich in blood supply so many of these flaps will still be quite successful. Patients who need any kind of reconstruction should stop smoking. They should also have their blood sugar under control if they are diabetic to lower the chance of getting an infection. Nutrition is important so patients should have adequate nutrition and adequate protein in order to heal their wounds.
In general, the basic wounds will be healed in a couple of weeks. Patients will have to do follow-up care with antibiotic ointments and removal of the sutures within the first one to two weeks.
In most patients, undergoing abbe or cross lip flaps, additional care of the wounds includes patients having their jaw wired shut during that two week span to prevent them from pulling the flap apart. They might have to be on a liquid diet for that entire time in order to prevent detaching the surgical repair.
Once the patient has a successful reconstruction, the new structure of the lips is pretty permanent. Sometimes there is scar tissue that might need corticosteroid injections to soften the scar. There are scar creams that can help scars heal faster and better over time.
Lip reconstruction is a lip enhancement procedure which can be necessary for a variety of reasons including trauma to the area, congenital issues or medical reasons such as cancer. A doctor or surgeon needs to perform a thorough examination of the patient to determine the cause of the problem as well as form a plan to treat the lip area. Lip reconstruction assists patients with visible changes in their appearance as well as dealing with any psychological issues resulting from an injury to the lips.
Written by Cosmetic Town Editorial Team- MA
Based on an exclusive interview with Shay Dean, MD in Marina Del Ray, CA